Social Determinants of Health, Maternal Involvement, and Child Development: Direct and Mediated Pathways

Objectives In the process of child development, a variety of factors are at play. In this regard, social determinants of health play a determining role in the development and growth of the child. This study aimed to design and test the model for social determinants of health for the development of 36-6o-month-old children in Tehran with the mediation of maternal involvement. Materials & Methods This cross-sectional study was conducted among 1067 mothers and their 36-60-month-old children in childcare centers in Tehran, using multistage sampling. Data gathering tools consisted of a demographic questionnaire for mothers and children, a questionnaire on unhealthy behaviors, Ages and Stages Questionnaire, Economic and Social Status Questionnaire, Perceived Social Support Questionnaire, Perceived Stress Questionnaire, Spielberger Anxiety Inventory, Beck Depression Inventory, ENRICH: Marital Satisfaction Scale, and Participation Scale for Parents and Mothers. Results Model fit measures were suitable and goodness of fit (RMSEA = 0.031, GFI = 1) was satisfactory. In addition, the results of path analysis indicated that the participation of mothers in the development of children had a direct positive (ß = 0.089) and increasing effect. Conclusion Findings indicated that depression, anxiety, stress, and marital satisfaction have both direct and indirect effects on the participation of mothers and child development. Moreover, the model fit measures indicated the utility and high proportionality of the model, as well as the logic of the adjusted relationships of variables based on the conceptual model.


Introduction
Global strategy and sustainable development goals emphasize children's health, requiring that each child survive, grow, and reach its development potential (1, 2). In the health system of a country, children's health is of utmost importance since it is the basis of the health of adolescents and future generations who are future parents and employees of a country. As a result, paying attention to children's health has advantageous effects both on the future of the health system of a country and the future functioning of citizens (3). Given that children are vulnerable, their development and growth are relevant to the health system of the society (4). Development in children is a process that improves children's physical, mental, emotional, and communicative interaction with people and environmental factors. This development process involves the onset of biological characteristics and behaviors stemming from experiential learning in the society (5).
Five developmental domains relevant in child development include fine motor skills, gross motor skill, communication skills, cognitive or problem-solving, and personal-social domains (6). Furthermore, early in life, healthy development enables children to have a flourishing life in domains such as social, emotional, cognitive, and physical well-being (7), which are negatively affected in case of any delays, leading to irreparable effects in the overall development process (8).
Nowadays, at least 200 million children around the world cannot reach their development potential (9). Baker et al. noted that when children do not acquire developmental abilities relevant to their age, they experience a developmental delay or disorder (10); this developmental delay is one of the top priorities of any health and treatment system in most countries (11). In pediatrics, developmental and behavioral problems are of great importance after infections and traumas (12). Additionally, the rate of developmental delays has been reported to be around 7 to 22.4% in different cities of Iran (13)(14). The development of the child's brain and its neural pathways is affected by biological factors (i.e., nutrition, infectious diseases, genetics and psychological and social factors) adolescence, pregnancy and childhood factors, as well as combined risk factors such as maternal depression (15). Nevertheless, maternal health, stress, poverty, literacy rate, perceived social support, parenting skills, maternity responsibilities along with housing burden can affect the conditions for participation in childcare (16), which in addition to child development is the number one parental responsibility (17). In this regard, the role of the mother starts and continues before and after childhood and contributes to the development of the child by providing a safe and caring environment for the child. The importance of the relationship between the child and his mother has been studied for decades, and empirically, lack of communication with the child has negative consequences in the neonatal and early childhood stages (18), such that participation of parents in the development process leads to greater and better opportunity for care, development, and health (19). This in return leads to increased social, cognitive, motor, and problemsolving skills, adaptive behaviors, emotional regulation, and higher educational performance in childcare centers and schools (20,21).
Research shows that health inequities start from infancy and early childhood. Accordingly, of all the factors related to child development, social determinants of health such as social class, social  (22)(23)(24). In addition, problems like the mental health of the mother affect both quality and quantity of care and attention given to the child and lead to severe childhood irritation and consequently to learning and behavioral problems (25,26). Also, maternal anxiety contributes to insufficient development of the child by minimizing the mother's abilities and negatively affecting reactions (27). Moreover, the findings of their study showed that a relationship between stressors and mental and emotional problems of parents on the one hand and the emotional problems as well as the delayed growth of children (28,29).
Further, poor social and economic level exposes the child to biological and psychological risk factors, as well as diseases, and leads to a change in brain structure and performance, which finally leads to developmental delay and learning deficiency (14,18). According to Emotional Security Theory, any occurrence of marital conflicts between parents compromises children's feelings, safety and the security inside the family and finally leads to parental depression which has negative effects on the child's developmental process (30).
Consequently, marital satisfaction influences the relationships between parents and children in a way that an inappropriate marital relationship worsens mother-child relationships for various reasons and even increases maternal depression, which in turn, affects the ability of the mother to respond to the child (31). In addition, results of different studies indicate that healthy development of the child is related to the mother's health as well as the social support received from others in the society; lack of this relationship can change mother's emotional signals, affecting child development on the whole (32, 33). or a single independent factor, as well as the fact that this study used path analysis as a suitable statistical method for studying child development and growth. The minimum score of both trait and state anxiety subscales is 20 and the maximum score is 80 (38).

Beck's Depression Inventory
This questionnaire is used to measure the severity of depression which includes 21 items rated on a 4-point scale ranging from 0 (symptom absent) to 3 (severe symptoms). From these 21 items, 2 items are related to affection, 11 items are related to recognition, 2 items are related to apparent behaviors, 5 items are related to somatic symptoms, and 1 item is related to interpersonal meaning. The minimum score is 0 and the maximum is 63. Scores up to 13: None or least depression, 14 to 19: mild depression, 20 to 28: moderate depression, and 29 to 63: severe depression (39).

Perceived Stress Scale (PSS-14)
The questionnaire is used to measure perceived public stress over the past month. The questionnaire consists of 14 items scored on a five-point Likert Iran J Child Neurol. Autumn 2020 Vol. 14 No. 4 scale ranging from 0 to 7, with 7 negative items indicating the inability to cope with stress and 7 positive items indicating the person's good handling of stressors. The lowest score on this scale is 0 and the highest score is 56 (40).

Social Support Appraisals (SS-A) Scale
This questionnaire consists of 23 items measuring how much a person believes in the interest and respect of family, friends, and others. The subscale of the family has 8 items, the subscale of friends has 7 items, and the subscale of the other includes 8 items. In this research, a modified form of social support questionnaire was used; therefore, each of the options, "yes" or "no", according to the content of sentences, was valued zero or one. The highest and lowest possible scores on this scale are 0 and 23 (41,42) .

ENRICH: Marital Satisfaction Scale (EMS)
This scale was used to examine marital satisfaction.
It consists of 35 items scored based on a five-point scale ranging from 1 to 5, and four subscales: marital satisfaction, communication, conflict resolution, and idealistic distortion. This questionnaire has 4 distinct scores for each subscale that are calculated for the total number of items for each subscale. In the end, raw scores are converted to percentages (43).

Ages and Stages Questionnaire (ASQ)
This is a parental reporting tool which examines movements, problem-solving ability, and personalsocial skills. There are 3 choices for each of the 30 questions: "yes", "sometimes," and "no". The answer "yes" is assigned 10 points, "sometimes" 5 points, and "no" 0 points. After completing the questionnaires, the scores were compared with the predefined cut-off points based on standardization, such that if the child in each of the five domains fails to reach the cut-off score, it means that he has problems in that area, and necessary specialist follow-up will be required to ensure health or the presence of a disorder or illness (44).

Parental involvement Scale
This scale consists of 32 items scored based on a Likert Scale ranging from 1 to 4. Based on the time limit in the five sections of one week, one month, days spent from this year, during the past months, and in general and item analysis, the items of the study were categorized into behavioral, cognitive, rational, and personal participation subparts (45).

Results
The results of this study showed that the mean age of mothers and fathers was 31.59 ± 5.    Table 5. In the present study, a significant relationship was found between socioeconomic status and maternal involvement. Socioeconomic status is one of the most important determinants of health and morbidity and is commonly used to describe social inequalities (46). Vellymalay (2012) believes that socioeconomic status has a stronger effect on involvement than other variables pertaining to parents, such as education (47). The results of the current study regarding socioeconomic status are consistent with those of the study carried out by Diamond et al. 2004 (48). In addition, Duncan and Magnuson referred to parental education, family income, family structure, neighborhood quality of life, and parents' social status as the factors influencing involvement (49). To account for the relationship between low involvement and low socioeconomic status, it can be claimed that parents' job limitations cause them to start working in jobs and locations that need commuting long distances from work to home. In addition, they have to work for long hours and get paid less; therefore, their socioeconomic status affects the amounts of time and energy that parents should devote to their children (50). On the other hand, low socioeconomic level is usually associated with parents' low level of education, which itself intensifies the reduced involvement in child development (51).
In the present study, stress, state anxiety, and trait anxiety had a significant relationship with marital satisfaction and maternal involvement.
Psychological problems are associated with feeling of disappointment and frustration, discomfort, loss of motivation and hope, reduced self-confidence, pessimism (52), loss of interpersonal relationships, disruptions in social relations, significant reduction of interest in enjoyable affairs, loss of energy, and deficiency in thinking and decision-making (53).
The above-mentioned consequences may constitute the factors leading to one's lower involvement in all family and social affairs, including health and education as well as children's development.
In studies, the influence of mothers' psychological factors on their involvement has been supported (54)(55)(56). According to research findings, high levels of maternal stress, which can arise from the stressful environment (57,58), have a negative effect on the mother's relationships with family members and are inevitably associated with less interaction with the child (57). Similarly, maternal stress affects the parenting role and leads to a decrease in emotional support towards children and, ultimately, it weakens the motherly role (59). Research has indicated that family involvement is positively correlated with the development of children from pre-school education to adulthood (70). Other studies have shown that parental involvement leads to increased cognitive skills, problem-solving skills, higher academic performance, and more interest in kindergarten, childcare center, and school; therefore, child behavioral problems are reduced (21). In fact, parental involvement plays a central and mediating role in beneficial outcomes for children (72).  All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.